Effect of end-of-life care planning discussions on hospice use among patients receiving dialysis for kidney failure / Lewis M. Cohen.

Format:

Book

Author/Creator:

Cohen, Lewis M., author.

Language:

English

Subjects (All):

Chronic renal failure--Complications.

Chronic renal failure.

Chronic renal failure--Diagnosis.

Physical Description:

1 online resource

Place of Publication:

Washington, DC : Patient-Centered Outcomes Research Institute (PCORI), 2020.

Summary:

BACKGROUND: End-of-life (EOL) care planning in patients with end-stage renal disease (ESRD) is a necessity, but this preparation occurs infrequently and thereby contributes to high health care utilization costs and decreased quality of life (QOL). Patients and families are interested in having conversations about EOL; however, providers are often not comfortable communicating on this topic. To address this communication gap, the Shared Decision-Making and Renal Supportive Care (SDM-RSC) project sought to create an easily replicable model for EOL care planning discussions in hemodialysis (HD) units. OBJECTIVES: Research aims included (1) improving EOL communication with a racially and ethnically diverse population at high risk of death from ESRD; (2) determining impacts on hospice use, location of death, and EOL advance-care planning; and (3) determining effect on QOL and caregiver satisfaction. METHODS: The SDM-RSC intervention consisted of an initial patient and family meeting with the dialysis social worker and nephrologist, followed by ongoing family contact with the social worker. Eighteen dialysis centers in New Mexico and western Massachusetts, operated by 3 proprietary dialysis chains, participated in the study. Patient and stakeholder advisory boards were established in both regions to influence all aspects of the research. An initial qualitative study used grounded theory to examine patient perspectives on EOL care planning, through interviews. This qualitative study informed the development and implementation of the intervention. The resulting quantitative study involved a prospective cohort (N = 125) that we followed for up to 18 months to examine how the intervention affected QOL and rates of death. Study participants were receiving maintenance HD and had poor prognoses as assessed with a validated prognostic instrument, which was based on age, albumin levels, peripheral vascular disease diagnosis, dementia diagnosis, and the "surprise question" (ie, physicians were asked if they would be surprised if that patient died in the next 12 months). Finally, we examined retrospective clinic-level data using an interrupted time-series design to assess the primary outcome (changes in hospice use over time). We conducted clinic-level analysis because we anticipated that the intervention would change the practice of the care team for all patients, not just for those involved in the intervention. RESULTS: Hospice rates for the general HD population are usually between 20% and 30%. Overall hospice rates using retrospective data did not vary significantly between the preintervention and postintervention periods; however, an examination of participants who died during the prospective study found that 48% stopped dialysis prior to death and 43% received hospice services. Although we did not collect data prospectively on non-enrolled patients, 75% of enrolled participants with follow-up had designated a health care proxy. Of participants, 63% completed Medical (or Physician) Orders for Life-Sustaining Treatment. QOL indicators did not change significantly within 6 months of the initial intervention meeting. CONCLUSIONS: Although we did not observe effects at a higher, clinic level in the retrospective cohort, important changes in EOL care planning did occur for individuals enrolled in the prospective study. To make the intervention more generalizable and practical for replication the study used existing staff at clinics from 2 regions of the United States, across 3 proprietary dialysis chains. LIMITATIONS AND SUBPOPULATION CONSIDERATIONS: The quasi-experimental time-series design used for the retrospective study does not have a concurrent nonintervention control group; therefore, other unmeasured secular changes may confound analyses. The primary threats to internal validity for the prospective cohort are the relatively small number of deaths and the potential for unaccounted attrition bias.

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